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Home My WebLink AboutBuilding Permit # 1/11/2016 BUILDING PERMIT %AoRry q ,�TLED lgx'Yo TOWN OF NORTH AOVER APPLICATION FOR PLAN EXAMINATION '_ R . Permit No##: ' Date Received � '°°R.,TEo '' .SSAGHUS Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER l d 1�4 �(.�1n1 ,o (,,o Print 1 100 Year Structure yes n MAP ARCEL: ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ElNew Building One family [IAddition [ITwo or more family 11Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other � WeI fiw ,�� 1i �^,�r:" 'mw'�fl�' wr,�' I III ��OW➢ � i p�'. V g NW'�'lvm!81 �� Jf iJ' 0 i IV u u 6 ESCRIPTION OF WORK TOB ERFOR ED: Identification- Please Type or Print Clearly OWNER: Name: i Phone: J (1 ' 2,1 C"I P Address: JC _l ylestC Contractor Name: Phone: Email Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.•$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. t� Total Project Cost: $ ��, FEE: $ Check No.: - Receipt No.: NOTE: Persons contractin with unregistered contractors do not have access to the guaranty fund � Vi,.�mn.a111, F.1�i r °, ! ! it//, i%' inra�:. A�Ilfri'''G 0, // ✓ ( /, %AORTH irown Andover 2 ', L 4 0. h ver, Mass, COC NICN WICK 1 'Q F V A �•9 °RATED PPaR�S S L1 11 BOARD OF HEALTH ERMIT D Food/Kitchen Septic System w a THIS CERTIFIES THAT ,.,,. BUILDING INSPECTOR ...................... ....®... ........ ............ K 4. ...... ,,�.. . . has permission to erect buildings on . V�� ..I............ Foundation Rough to be occupied as ... ® ...................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final EXPIRESPERMIT ® S ELECTRICAL INSPECTOR LES TI T Rough Service .................. ..................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired t® Occupy Puildin Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector® Burner Street No. Smoke Det. F t%ORT{i TOWN OF NORTH ANDOVER 0 OFFICE OF 0 40- 0 0 UILDING DEPARTMENT TENT 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 �SSACHUS�� Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: umber Street Address rrMap/Lot HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS W Nj. (� R City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license, ron vided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR Section IIO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of assachusefis _ Department of IndustrialAceldents 1 Congress Street,Suite 100 Boston,MA 02114-2017 ~: a www.rnass.gov/dia Workers'Compensation insurance Afridavit:Builders/Contractors/Elec rleiansfRiumbers. TO BE FILED WITH THE PEI2lb.ILTTING AUTHORITY. Please Print Ile ibl AppjicantInformation Name(Business/Organization/Individual): Address: City/Mate/Zip: �U , �0 hone Are-you an employer?CltecIctIie appropriate box: Type of project(.Tg fired): 1.p I am a employer with employees(full and/or part-ti-0-4: 7. New construction 2. I am a sole proprietor or partnership and have no employees Working for me in 8. 5Remodelhig any capacity.[No-workers'comp.insurance required.] 9. Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t ]0 n Building addition 4)4I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11 ❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole ; proprietors withno employees. 12.d Plumbing repairs or additions 5.[]I am a general contractor and I Kaye hired the sub-contractors listed onthe attached sheet. 13.0 Roof repairs These sub-contractors bade employees and have workers'comp.insurance. 14. Other 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c, 152,§1(4),and we have nn,employees.(No workers'comp.insurance required.] FAny applicant that checks box#i must also fill outthe sectionbelow showingtheirworkers'compensation policy information. Homeowners wlto submit this affidavit indicating they are doing all wont andthen hire outside contractors must submit a new affidavit indicating such. ?Contractors that check this box must'attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Ifthe sub-conlractozs have employees,l[iey must provide their workers'comp.policy number. 1 am an erriployer'tTiat isproviding worTcers'compensation insurance for my employees.'..below is the policy and joh site information. Insurance Company Name: Policy#or Self-ins,Lic.#: Expiration Date: rob Site Address: City/State/Zip: Attach.a copy of the workers' compensation.policy declaration page(showing the policy ninub rand expiration date). Failure to secure coverage as required under MGI,o. 152,§25A is a criminal violation punishable by a fine up to$1.,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certy under thepains andpenalties ofperjurn)that the information proviaed above is true and correct. Date: / sign Phone#: G Official use only. Do notrtvrite in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical inspector 5.Plumbing Inspector 6,Other Contact Person: Phone#: